Elsevier

Psychiatry Research

Volume 251, May 2017, Pages 142-147
Psychiatry Research

New DSM-5 PTSD guilt and shame symptoms among Italian earthquake survivors: Impact on maladaptive behaviors

https://doi.org/10.1016/j.psychres.2016.11.026Get rights and content

Highlights

  • 41,7% of the sample presented a PTSD diagnosis.

  • 11,6% reported at least a guilt and shame symptom.

  • Guilt and shame symptoms were reported more frequently in survivors with PTSD.

  • Guilt and shame were related significantly to PTSD symptoms and maladaptive coping.

Abstract

Important changes were introduced concerning posttraumatic-stress disorder (PTSD) by the DSM-5 recognizing the role of negative emotions such as guilt and shame, but little evidence is yet available on their prevalence in population assessed by means of DSM-5 criteria. In this study we explored the rates of guilt and shame DSM-5 PTSD diagnostic symptoms among Italian survivors to a massive earthquake and their possible correlation with PTSD and maladaptive behaviors. 869 residents of the town of L'Aquila exposed to the earthquake of April 6th, 2009 were investigated by the Trauma and Loss Spectrum-Self Report (TALS-SR) with particular attention to guilt and shame feelings. DSM-5 symptomatological PTSD was reported by 41.7% of survivors, further 11.6% endorsed at least one guilt/shame symptoms, with significantly higher rates of endorsement were in PTSD respect to No-PTSD subjects, and in the subgroup with at least one maladaptive behavior respect to those with none. There was a significant main effects of PTSD and at least one guilt/shame symptom on TALS-SR symptomatological domains. Mean TALS-SR Maladaptive coping domain score appeared significantly higher in the subgroup with at least one guilt/shame symptom. Further study are needed to investigate guilt and shame feelings in survivors to a natural disaster.

Introduction

Important changes were introduced for posttraumatic-stress disorder (PTSD) by the last edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association, 2013). Besides devoting an autonomous chapter from that of anxiety disorders to trauma and stress related disorders, the DSM-5 defined new four symptomatological criterion structure for PTSD and recognized the central role of other forms of negative emotions besides fear and anxiety, such as guilt and shame (Beck et al., 2011, Friedman et al., 2011; American Psychiatric Association, 2013; Power and Fyvie, 2013; Badour et al., 2015). In particular, two new symptoms were added to existing diagnostic criteria, reflecting the importance attributed to negative emotions, particularly symptoms D3, “persistent distorted blame of self or others about the cause of consequences of the trauma” and D4, “persistent negative emotional state, for example: fear, horror, anger, guilt or shame”.

Guilt and shame are moral emotions characterized by negatively valenced self-evaluation, on entire self or on a specific action (Lewis, 1971, Tangney and Dearing, 2002, Tangney et al., 2007, Tracy and Robins, 2004). Higher levels of PTSD have been associated to higher levels of guilt (Kubany, 1994, Pugh et al., 2015). Henning and Frunch (1997) reported a significant positive association between guilt feelings and PTSD symptoms severity in combat veterans with PTSD. The same emerged in civilian samples among men convicted of having caused someone's death through reckless driving (Lowinger and Solomon, 2004), and women who had experienced intimate partner violence (Bean and Möller, 2002), suggesting guilt as a possible important concomitant of PTSD in a variety of trauma samples. Further, differences in the levels of guilt feelings reported have been highlighted in patients survived to different types of trauma. Evidence from research on veterans with PTSD have shown the importance of the so called “combat guilt”: guilt about the people, especially women and children, killed while on duty (Friedman, 1981, Ganz and Sher, 2013). Other studies have suggested how combat guilt should not only be considered a core affective feature of combat-related PTSD (Litz et al.,2009), but also one of the strongest predictor of suicidality among military personnel (Bryan et al., 2012). Guilt feelings have also been described in civilian populations survived to mass traumatic events, with the two types most reported being “Survivor guilt” (I should not have survived) and “Performance guilt” (I should have done better). Hull et al. (2002), in a study among 33 survivors from an oil platform disaster reported these symptoms in more than one-third of the sample.

Shame related to a traumatic event is frequently reported and has been particularly studied in subjects exposed to interpersonal and war-related traumas (Kubany et al., 1996; Dorahy et al., 2013; Stotz et al., 2015). Evidences show a relationship between shame and PTSD development in battered women and victims of violent crimes (Andrews et al., 2000; Street and Arias, 2001). Further, PTSD intrusive, avoidance and hyperarousal symptoms severity has been related to the intensity of shame in veterans and in refugee adolescents exposed to various traumas (Henning and Frueh, 1997, Leskela et al., 2002; Stotz et al., 2015)

The DSM-5 introduced another important novelty among diagnostic criteria for PTSD that is the new criterion E2 on “reckless or self-destructive behaviors” (American Psychiatric Association, 2013). Maladaptive behaviors have been defined as volitional behaviors whose outcome is uncertain and which entail negative consequences that impact everyday activities (Irwin, 1990, Pat-Horenczyk et al., 2007; Hartley et al., 2008; Dell'Osso et al., 2012a, Dell'Osso et al., 2013b, Dell'Osso et al., 2012b; Carmassi et al., 2014b). The role of these behaviors in PTSD patients, like risk-taking behaviors, dangerous driving or promiscuous sex, is evidenced by an increasing amount of literature (Dell'Osso et al., 2011a, Dell'Osso et al., 2013b; McMillen et al., 2000, Bal and Jensen, 2007; Goenjian et al., 2009; Cairo et al., 2010). Significantly higher rates of violent behaviors were found in Iraq and Afghanistan war veterans with PTSD, compared to those without PTSD (Jakupcak et al., 2007, Elbogen et al., 2010). Male veterans also showed aggressive and unsafe driving (Fear et al., 2008, Kuhn et al., 2010). Even the medication non-adherence rate resulted higher in veterans with PTSD respect to those without (Kronish et al., 2012). Adolescents and young adults with PTSD due to terrorism, fire, or violence, showed risk-taking behaviors, such as smoking, alcohol, and substance use, car racing, weapon carrying, violence, and delinquency (Goldich and Allen, 1998; Stevens at al., 2003; Dell'Osso et al., 2013b). Some studies reported higher rates of maladaptive behaviors in victims with PTSD compared to non-affected subjects, with boys reporting significantly higher rates than girls (Glodich and Allen, 1998, Sugar, 1999; Gore-Felton and Koopman, 2002; Stevens et al., 2003).

Earthquakes are one of the most frequent natural disasters throughout the world affecting numbers of people, often striking unexpectedly, threatening lives and leading to large scale destruction (Armenian et al., 2000, Bödvarsdottir and Elklit, 2004, Lai et al., 2004; Bland et al., 2005; Chang et al., 2005; Önder et al., 2006; Wang et al., 2011; Priebe et al., 2010; Ehring et al., 2011). Extensive research has been conducted on mental disorders following earthquakes as the mental distress associated with these experiences poses relevant challenges to mental health services (Armenian et al., 2002, Goenjian et al., 2005, Kun et al., 2009, Hussain et al., 2010), and most recently in Italy, particularly after the L'Aquila earthquake of 2009 (Dell'Osso et al., 2011a, Dell'Osso et al., 2011b, Dell'Osso et al., 2013a; Carmassi et al., 2013, 2014a, 2015). Italy is one of the most seismically active countries in Europe but it is unusual for the Country to experience deadly earthquakes, such as that Richter Magnitude 6.3 which stroke the town of L'Aquila on April 2009. Because of the earthquake most of the town was destroyed, 309 people died and more than 1600 individuals were injured and 66,000 displaced. We recently reported rates of symptomatological PTSD, assessed, by means of spectrum instrument for post-traumatic stress symptomatology named trauma and loss spectrum-self report (TALS-SR) (Dell'Osso et al., 2009, Dell'osso et al., 2008) and according to DSM-5 criteria of 39.8% among survivors to this event, with higher rates among women and bereaved subjects (Dell'Osso et al., 2011a; Carmassi et al., 2013, 2014a). On a sample of 900 survivors to the 2009 L'Aquila earthquake, we also found high prevalence rates of maladaptive behaviors among survivors, significantly higher in those with PTSD with respect to those without. Higher rates of maladaptive behaviors were also found in males with PTSD with (69.4%) respect to females (56.6%) (Dell'Osso et al., 2013b).

The aim of the present study was to explore the presence of the newly introduced guilt and shame PTSD diagnostic symptoms among 869 survivors to the L’Aquila earthquake as well as their possible correlation with PTSD and maladaptive behaviors.

Section snippets

Study participants

The target population included residents of the town of L'Aquila, who lived in the urban area of the town and have been directly exposed to the earthquake of April 6th, 2009 and received assistance in the emergency conditions that prevailed being displaced in locations within a 150 km area from the town or in tents located in the urban area. All subjects were enrolled 10 months after the earthquake, at that time only 25% of the inhabitants were able to return to their homes.

The assessment

Results

In the total sample a symptomatological PTSD diagnosis, according to DSM-5 criteria (American Psychiatric Association, 2013), was reported by 362 (41.7%) of survivors. Further, 101 (11.6%) subjects endorsed at least one guilt/shame symptom. Rates of endorsement of at least one guilt/shame symptom were significantly higher in PTSD with respect to No-PTSD subjects [n=69 (19.1%) vs n=32 (6.3%), p<0.001] and in the subgroup with at least one maladaptive behavior respect to those with no one [n=57

Discussion

To the best of our knowledge we are the first to report the rates of the recently introduced symptoms of guilt and shame, among DSM-5 PTSD diagnostic criteria, in a large population sample exposed to a natural disaster. We found feelings of shame, guilt or self-blame in 11,6% of survivors at some point after exposure to the L'Aquila earthquake, with significantly higher rates of endorsement in subjects with a PTSD diagnosis compared to those without. In addition, we found that the presence of

Conflict of interest

No conflict declared.

Contributors

Claudia Carmassi, Liliana Dell’Osso and Alessandro Rossi participated to the conception and design of the study. Claudia Carmassi, Carlo Antonio Bertelloni and Liliana Dell’Osso participated to the interpretation of the data, the draft and critical revision of this article. Gabriele Massimetti undertook the statistical analysis. Camilla Gesi, Paolo Stratta and Alessandro Rossi participated to the critical revision of the manuscript. All authors agreed to be cited as co-authors, accepting the

Role of funding source

The present study was supported by the Universities of Pisa and L'Aquila, no other economic source was interested.

Acknowledgments

none.

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